|
-orm'so
<br />Request for Taxpayer
<br />Give Form to the
<br />'Rev. December 2014)
<br />Identification Number and Certification
<br />requester. Do not
<br />Japarlment
<br />of the Treasury
<br />send to the IRS.
<br />Infernal
<br />Revenue Service
<br />1 Name (as shown on your Income tax return). Name is required on this line; do not leave this line blank.
<br />of
<br />2 Business name/disregarded entity name, if different from above
<br />m
<br />m
<br />m
<br />�-
<br />3Check appropriate box for fedemltax dassNipfion; check only one of the following seven bones:
<br />4Fxemptions (codes apply only to
<br />m
<br />❑ Indlvidual/sole proprietor or ❑ C Corporation ❑ S Corporation p ❑ TrusVestate
<br />❑ Partnership
<br />certain entitles, not individuals; see
<br />Instructions on page 3):
<br />m
<br />me
<br />o- m
<br />�5
<br />single -member LLC
<br />Limited liability company. Enter the tax classification C=C torr emtlon, S=S corporation, P= artnershi ®
<br />❑ p y ( p p p)
<br />Exempt payee code Of my)
<br />`o
<br />Note. For a single -member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
<br />Exemption from FATCA reporting
<br />a m
<br />the tax classification of the single -member owner.
<br />code Of any)
<br />c
<br />a` o
<br />❑Other (see instructions)®
<br />(nppu'es,a axoumsmaaremrewmee uxusl
<br />'uw
<br />5 Address (number, street, and apt. or suite no.)
<br />Requester's name and address (optional)
<br />m
<br />a
<br />m
<br />6 City, state, and ZIP code
<br />m
<br />m
<br />7 List account numbers) here (optimal)
<br />IM Taxpayer Identification Number (TIN)
<br />Ester your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid I Social security number
<br />backup withholding. For individuals, this is generally your social security number ( However, far a
<br />page _ m —�
<br />resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
<br />entitles, it is your employer identification number (EIN). If you do not have a number, see How to get
<br />TIN on page 3. or
<br />Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for I Employeridentificatienrrumber
<br />guidelines on whose number to enter. F—F-1
<br />Under penalties of perjury, I certify that:
<br />1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
<br />2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
<br />Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
<br />no longer subject to backup withholding; and
<br />3. 1 am a U.S. citizen or other U.S. person (defined below); and
<br />4. The FATCA code(s) entered on this form (if any) Indicating that I am exempt from FATCA reporting is correct.
<br />Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
<br />because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
<br />interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
<br />generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
<br />instructions on page 3.
<br />sign Signature of
<br />Here I U.S. person b- Date ►
<br />General Instructions
<br />Section references am to the Internal Revenue Code unless otherwise noted.
<br />Future developments. Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release it) is at wwmks.goy1lw9.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who Is required to file an Information
<br />return with the IRS must obtain your correct taxpayer Identification number (TIN)
<br />which may be your social security number (SSN), individual taxpayer Identification
<br />number (ITIN), adoption taxpayer Identification number (ATIM, or employer
<br />identification number (EIN). to report on an information return the amount paid to
<br />you, or other amount reportable on an information return. Examples of Information
<br />returns include, but are not limited to, the following:
<br />• Form 1099 -INT (interest earned or paid)
<br />• Form 1099 -DIV (dividends, including those from stocks or mutual funds)
<br />• Form 1099-MISC (various types of income, prrzes, awards, or gross proceeds)
<br />• Form 1099-B (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099-S (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />• Form 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T
<br />(tuition)
<br />• Form 1099-C (canceled debt)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only if you are a U.S. person (Including a resident alien), to
<br />provide your correct TIN.
<br />If you do not return Form W-9 to the requester with a TIN, you might be subject
<br />to backup withholding. Sea What is backup withholding? on page 2.
<br />By signing the filled -out form, you:
<br />1. Certify that the TIN you are giving is correct (or you are waiting for a number
<br />to be Issued),
<br />2. Certify that you are not subject to backup withholding, or
<br />3. Claim exemption from backup withholding if you are a U.S, exempt payee. If
<br />applicable, you arra also certifying that as a U.S. person, your allocable share of
<br />any partnership Income from a U.S. turtle or business is not subject to the
<br />withholding tax on foreign partners' share of effectively connected income, and
<br />4. Certify that FATCA code(s) entered on this form (f any) indicating that you are
<br />exempt from the FATCA reporting, is correct. Sea What is FATCA reporting? on
<br />page 2 for further information.
<br />Cat. No. 10231X
<br />75D-147
<br />Form W-9 (Rev. 12-2014)
<br />
|